Nicolas Brassart

Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?

BACKGROUNDnGood functional results have been reported for arthroscopic repair of rotator cuff tears, but the rate of tendon-to-bone healing is still unknown. Our hypothesis was that arthroscopic repair of full-thickness supraspinatus tears achieves a rate of complete tendon healing equivalent to those reported in the literature with open or mini-open techniques.nnnMETHODSnSixty-five consecutive shoulders with a chronic full-thickness supraspinatus tear were repaired arthroscopically in sixty-five patients with use of a tension-band suture technique. Patients ranged in age from twenty-nine to seventy-nine years. The average duration of follow-up was twenty-nine months. Fifty-one patients (fifty-one shoulders) had a computed tomographic arthrogram, and fourteen had a magnetic resonance imaging scan, performed between six months and three years after surgery. All patients were assessed with regard to function and the strength of the shoulder elevation.nnnRESULTSnThe rotator cuff was completely healed and watertight in forty-six (71%) of the sixty-five patients and was partially healed in three. Although the supraspinatus tendon did not heal to the tuberosity in sixteen shoulders, the size of the persistent defect was smaller than the initial tear in fifteen. Sixty-two of the sixty-five patients were satisfied with the result. The Constant score improved from an average (and standard deviation) of 51.6 +/- 10.6 points preoperatively to 83.8 +/- 10.3 points at the time of the last follow-up evaluation (p < 0.001), and the average University of California at Los Angeles score improved from 11.5 +/- 1.1 to 32.3 +/- 1.3 (p < 0.001). The average strength of the shoulder elevation was significantly better (p = 0.001) when the tendon had healed (7.3 +/- 2.9 kg) than when it had not (4.7 +/- 1.9 kg). Factors that were negatively associated with tendon healing were increasing age and associated delamination of the subscapularis or infraspinatus tendon. Only ten (43%) of twenty-three patients over the age of sixty-five years had completely healed tendons (p < 0.001).nnnCONCLUSIONSnArthroscopic repair of an isolated supraspinatus detachment commonly leads to complete tendon healing. The absence of healing of the repaired rotator cuff is associated with inferior strength. Patients over the age of sixty-five years (p = 0.001) and patients with associated delamination of the subscapularis and/or the infraspinatus (p = 0.02) have significantly lower rates of healing.

All-Arthroscopic Weaver-Dunn-Chuinard Procedure With Double-Button Fixation for Chronic Acromioclavicular Joint Dislocation

PURPOSEnWe described a novel all-arthroscopic technique of coracoclavicular ligament reconstruction and reported the early clinical and radiologic results of this procedure.nnnMETHODSnWe performed all-arthroscopic coracoclavicular ligament reconstruction in 10 consecutive patients (8 men and 2 women; mean age, 41 years) with a symptomatic chronic and complete acromioclavicular (AC) joint dislocation (Rockwood type III or IV). Four patients had undergone surgery previously: two had initial pinning of the acute AC joint separation, and two had a subsequent Mumford procedure. The surgical technique, performed entirely by arthroscopy, consisted of (1) rerouting the coracoacromial ligament with a bone block harvested from the tip of the acromion in a socket created in the distal clavicle (Chuinards modification of the Weaver-Dunn procedure) and (2) augmenting the reconstruction with 2 titanium buttons connected by a heavy suture in a 4-strand configuration (Double-Button fixation; Smith & Nephew Endoscopy, Andover, MA). Patients were prospectively followed up for a mean of 12.8 months (range, 6 to 20 months).nnnRESULTSnOne patient had a superficial infection of the superior (clavicular) portal, which resolved with oral antibiotics. At the most recent review, all patients were satisfied or very satisfied with the cosmesis, and 9 of 10 returned to previous sports, including contact and overhead sports. All symptoms resolved (pain, shoulder weakness, paresthesia). The mean postoperative University of California, Los Angeles modified AC rating score was 16.5 points (range, 13 to 18 points) out of 20 points. The mean Subjective Shoulder Value improved from 36% (range, 0% to 70%) preoperatively to 82.5% (range, 70% to 100%) postoperatively (P = .005). The bone block was totally healed in the medullary canal in 8 cases and partially healed in 2. No loss of reduction was observed in any of the patients.nnnCONCLUSIONSnOur study shows that severe chronic symptomatic AC joint separations, defined as Rockwood types III through V, can be repaired entirely by arthroscopy safely and effectively by transferring the coracoacromial ligament with a bone block in the distal clavicle. The bone block transfer (Weaver-Dunn-Chuinard procedure) has the advantage of making the repair easier and stronger, and it provides bone-to-bone healing by use of free, autologous vascularized tissue. Double-Button fixation has the advantage of maintaining the reduction during the biological healing process. Although the durability of the reconstruction remains unproven, in our short-term follow-up we observed no loss of reduction and the functional and cosmetic results were uniformly good.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

28 Perte de pression entre l’interface tendon-os dans les réparations de la coiffe des rotateurs fixées par ancres et sutures

Introduction Le but de cette etude etait d’etudier la pression au niveau de l’interface os-tendon, ainsi que la zone de contact et la force durant la realisation de la fixation et au cours de l’heure suivante. Materiel et methode La fixation du tendon sur l’os etait realisee d’une maniere identique a celle realisee lors d’une reparation de la coiffe des rotateurs de l’epaule a ciel ouvert. Nous avons compare trois types de suture (Ethibond, PDS, Orthocord) en utilisant la meme technique de reparation. Chaque tendon etait rattache a l’aide d’un point en « U » a une meme ancre metallique (Fastin, Mitek, vis metallique) et avec un meme nœud (noeud de chirurgien). Huit epaules d’ovins fraiches ont ete utilisees. Pour chaque epaule, une suture de chaque type a ete testee. Entre chaque reparation, un capteur de pression (150 psi, Tekscan) etait mis en place entre le tendon et l’os afin d’enregistrer de maniere continue les differentes donnees (pression en KPa, aire de contacte en mm 2 et force en Newton). Le systeme « Tekscan » nous a permis de surveiller les pressions durant toute la phase de realisation du nœud et au cours de l’heure suivante. Resultats Il existait une perte de 60 % de la force de contact et de 50 % de l’aire de contact entre le debut de la realisation du nœud et une fois ce dernier realise. De plus, apres une heure de fixation, la perte de force etait de 86 % et la perte de contact entre le tendon et l’os de 66 %. Des trois sutures, le PDS etait statistiquement la meilleure suture permettant de maintenir le plus fort taux de pression, de force et de contact durant la premiere heure. Entre les deux sutures tressees, l’Orthocord apparaissait statistiquement meilleure que l’Ethibond. Conclusions Il existe une perte de force, de pression et de l’aire de contact entre l’interface os-tendon dans les reparations de coiffe a ciel ouvert qui commence immediatement apres la fixation et se poursuit la premiere heure. Ces resultats prouvent que les donnees sur la fixation tendineuse doivent tenir compte des changements de pression qui se produisent avec le temps quel que soit le type de suture utilisee.